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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />r1+e'✓e0'P' <br />FACILITY ID # <br />/A00/7 7.37 <br />SERVICE REQUEST # <br />SjQ����1�� <br />OWNER /OPERATOR <br />6 G/ t, Al VD L� li �-o W14 ! c O /Jex 4 �90 41 s� ,v1 14 � �C1ECK If BILLING ADDRESS <br />FACILITY NAME --- <br />G v v o �+ ✓ �� // c vt <br />!oo zo�8 <br />SITE ADDRESS;F,- ', i y /JAY <br />�9V O 'Street Number <br />Direction <br />�G� / 1 1 y %�`• v1� :✓=i <br />Street Name <br />�� Q c!4 !n <br />✓ city <br />! Z C% <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 EXT. <br />( ) <br />APN # <br />DATE: <br />J\ <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />EMPLOYEE #: 3 -C -) <br />C I <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK If BILLING ADDRESS <br />COMMENTS: <br />!oo zo�8 <br />BUSINESS NAMEPHONE <br />A <br /># EXT. <br />HOME or MAILING ADDRESS <br />,3a 417t< !y Avg <br />,SN , /r, <br />O� ' �N�Y <br />rMFNT <br />FAX # <br />(> 6N� 476 5, <br />CITY 1 1 <br />STATE C � _'/� ZIP _7 <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br />activity will be billed to me or my business as identified on this form. <br />also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: _Z / <br />PROPERTY / BUSINESS OWNER ElOPERATOR/ MA GER 171r G !4 OTHER AUTHORIZED AGENT ❑ jGrl;� H cr 7 <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required T','& <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site asselfim ent information <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT a5 soon as it IS available and at the same time It iM �' to me or <br />my representative.,,'; ./fty„ <br />TYPE OF SERVICE REQUESTED: <br />zh ,ki <br />COMMENTS: <br />!oo zo�8 <br />E UjN o <br />H <br />O� ' �N�Y <br />rMFNT <br />ACCEPTED BY: <br />' <br />EMPLOYEE #:C, C I <br />DATE: <br />J\ <br />ASSIGNED TO: <br />EMPLOYEE #: 3 -C -) <br />C I <br />DATE: - i - 1C' <br />J, <br />Date Service Completed (if already completed . <br />SERVICE CODE: � C j R I P/ E:f 3—, <br />Fee Amount: C <br />Amount Pal / <br />a d b <br />Payment Date IzLI <br />Payment Type l' <br />Invoice # <br />Check # <br />ReceiWd By: <br />EHD 48-02-025�,�p <br />07(17/08 Wit( �1� SR FORM (Golden Rad) <br />` ` <br />